What is the first line of treatment for hyperparathyroidism?

From the Guidelines

The first line of treatment for hyperparathyroidism is surgical excision of the abnormally functioning parathyroid tissue, specifically parathyroidectomy, which is typically indicated even in asymptomatic patients due to the potential negative effects of long-term hypercalcemia. This approach is supported by the most recent evidence from the Journal of the American College of Radiology 1, which highlights the importance of surgical treatment in managing primary hyperparathyroidism (PHPT).

Key Considerations for Treatment

• The treatment of PHPT is primarily surgical, with two accepted curative operative strategies: bilateral neck exploration (BNE) and minimally invasive parathyroidectomy (MIP) 1.
• MIP is often preferred for patients with a single adenoma, as it offers the benefits of shorter operating times, faster recovery, and decreased perioperative costs 1.
• Preoperative localization of the parathyroid adenoma is crucial for successful MIP, and intraoperative PTH monitoring is used to confirm the removal of the hyperfunctioning gland 1.

Medical Management

For asymptomatic patients who do not meet surgical criteria or are poor surgical candidates, medical management may be considered. This can include the use of bisphosphonates or cinacalcet to lower calcium levels, along with adequate hydration and a low-calcium diet 1. However, surgery remains the definitive treatment for hyperparathyroidism, offering a cure rate exceeding 95% when performed by experienced surgeons. Regular monitoring of serum calcium, parathyroid hormone levels, and bone density is essential for non-surgical patients to prevent long-term complications.

Surgical Approach

The choice between BNE and MIP depends on various factors, including the presence of a single adenoma, multigland disease, or discordant preoperative imaging 1. BNE is often necessary in cases of multigland disease or when preoperative imaging is non-localizing. In contrast, MIP is suitable for patients with a single adenoma and precise preoperative localization. The goal of surgery is to remove the abnormally functioning parathyroid tissue, thereby normalizing calcium metabolism and preventing long-term complications.

From the FDA Drug Label

Cinacalcet tablets are indicated for the treatment of hypercalcemia in adult patients with primary HPT for whom parathyroidectomy would be indicated on the basis of serum calcium levels, but who are unable to undergo parathyroidectomy The first line of treatment for primary hyperparathyroidism is typically parathyroidectomy, but for patients who are unable to undergo surgery, cinacalcet can be used to treat hypercalcemia.

• The recommended starting oral dose of cinacalcet tablets is 30 mg twice daily for patients with primary hyperparathyroidism.
• The dose of cinacalcet tablets should be titrated every 2 to 4 weeks as necessary to normalize serum calcium levels 2

From the Research

Hyperparathyroidism Treatment

The first line of treatment for hyperparathyroidism is typically surgical, with parathyroidectomy being the definitive therapy for primary hyperparathyroidism (PHPT) 3.

• Surgical Indications: Surgery is indicated for all patients with symptomatic primary hyperparathyroidism, as well as asymptomatic individuals who are younger than 50 years, have severe hypercalcemia, markedly reduced creatinine clearance, and/or profound osteopenia 3.
• Medical Management: For patients who cannot or do not want to undergo surgery, medical management options are available, including calcium and vitamin D supplementation, and pharmacological approaches such as cinacalcet and bisphosphonates 4.
• Cinacalcet: Cinacalcet is a calcimimetic that can help control hypercalcemia in patients with PHPT, and has been shown to be effective in normalizing serum calcium levels in renal transplant patients with persistent hyperparathyroidism 5.
• Combination Therapy: Combination therapy with cinacalcet and alendronate has been shown to be effective in normalizing hypercalcemia and improving bone mineral density in patients with PHPT 6.

Treatment Goals

The goals of treatment for hyperparathyroidism include:

• Normalizing serum calcium levels
• Improving bone mineral density
• Reducing the risk of complications such as kidney stones and osteoporosis
• Improving quality of life for patients with symptomatic disease

Treatment Options

Treatment options for hyperparathyroidism include:

• Parathyroidectomy: surgical removal of all hyperfunctional parathyroid tissue
• Medical management: calcium and vitamin D supplementation, pharmacological approaches such as cinacalcet and bisphosphonates
• Combination therapy: cinacalcet and alendronate
• Minimally invasive parathyroidectomy: a surgical technique that uses preoperative localization to enable a less invasive procedure 7